Referral Form. Survey

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* 1. Full name

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* 2. Date of Birth

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* 3. Contact Details

Address

Address 2

Town

County

Post Code

Email Address

Phone Number

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* 4. Emergency contact name and contact number:

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* 5. Relationship to Child

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* 6. Children/Young persons details (Child 1):

Name

Date of Birth

Any Additional Needs?

Does your child live with yourself?

Any Social Care involvement?

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* 7. Children/Young persons details (Child 2):

Name

Date of Birth

Any Additional Needs?

Does the child live with yourself?

Any Social Care involvement?

N/A

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* 8. Children/Young persons details (Child 3):

Name

Date of Birth

Any Additional Needs?

Does the child live with yourself?

Any Social Care involvement?

N/A

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* 9. Children/Young persons details (Child 4):

Name

Date of Birth

Any Additional Needs?

Does the child live with yourself?

Any Social Care involvement?

N/A

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* 10. If you have more than 4 children, please answer 'Yes' below and we will contact you for their details.

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* 11. Please give details of any services working with the family below.

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* 12. Reason for referral, Please give us as much information as possible around how we can support you and if you have seen a course advertised that you would like to attend please inclde this.

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* 13. I am interested in the following courses / workshops

Coping With Challenging Behaviour - 18th November - Microsoft Teams - 11am - 1:30pm

ADHD Workshop - 1 session - 2nd December - Microsoft Teams- 11am - 1:30pm

ADHD Workshop - 1 session - 26th November - Jaywick Community Resource Centre 11am - 1:30pm

Emotional regulation - 1 session. 16th december Microsoft Teams - 11am - 1:30pm

NVR Non Violence Response training - 9 weeks

Step By Step - Early years (2 - 4 years) - 9 Weeks

Step By Step - Primary years (4-11 years) - 9 Weeks

Incredible baby years

Mindfulness - 6 Weeks

Managing Anxiety - 7 weeks

Improving Your Emotional Wellbeing - 5 weeks

Building confidence - 9 weeks

ADHD Workshop - 1 session

Coping with defiant behaviour - 1 session

SWAN(Support With Additional needs) - 11 weels

Resilience Workshops - For parent's of children with SEND - 4 weeks

STOP (Supportive programme for parenting teenagers) - 11 Weeks

Other (please specify)

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* 14. Where did you hear about EXTRA? If via your child's school please tell us which.

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* 15. I consent to my personal details being kept on a secure database to be contacted by EXTRA, all data is kept confidential in compliance with GDPR.

Please note Patients of North Colchester PCN -
CONSENT TO SHARE - we will share your attendance and feedack with North Colchester PCN (Your current GP Provider)

WITHDRAWING CONSENT

You have the right to withdraw consent to EXTRA storing your information, or any part of it, at any time. If you wish to do so, please contact EXTRA:

Post: Extra – Support for Families, Jaywick Community Resource Centre, Brooklands Gardens, Jaywick CO15 2JP

Email: admin@extrasupportforfamilies.co.uk

Phone: 01255 475001

I consent